HI II Exam 1 Questions and Answers
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-
rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse
responsible for this patient's care, you would anticipate a physician order for what action?
A) Perform endotracheal intubation and initiate mechanical ventilation.
B) Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and
mouth.
C) Administer furosemide (Lasix) 100 mg IV push stat.
D) Call a code for respiratory arrest.
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway
management should you delegate to a nursing assistant?
A) Assisting the patient to sit up on the side of the bed.
B) Instructing the patient to cough effectively.
C) Teaching the patient to use incentive spirometry.
D) Auscultation of breath sounds every 4 hours.
When assessing a 22-year old patient who required emergency surgery and multiple transfusion
3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38
breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal
cannula. Which action is most appropriate?
A) Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10
minutes.
B) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he
coughs.
C) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the
hyperventilation.
D) Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to
discuss the patient's status.
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7
mEq/L. Which intervention is delegated correctly to the student nurse?
A) Give potassium 10 mEq orally
B) Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
C) Give spironolactone (Aldactone) 25 mg orally
D) Assess the electrocardiogram (ECG) strip for tall T waves
ECF is primarily composed of:
A) Aqueous fluid and lymphatic fluid.
, B) CSF and interstitial fluid.
C) Interstitial and intravascular fluids.
D) Vascular fluid and CSF.
A clinical manifestation not found in hypokalemia is:
A) Muscle weakness
B) Oliguria
C) Postural hypotension
D) Bradycardia
Nursing intervention for a patient with a diagnosis of hyponatremia includes all of the following
except:
A) Assessing for symptoms of nausea and malaise.
B) Encouraging the intake of low-sodium liquids such as coffee or tea.
C) Monitoring neurologic status
D) Restricting tap water intake.
The most characteristic manifestation of hypocalcemia and hypomagnesemia is:
A) Anorexia and nausea.
B) Constipation
C) Lack of coordination
D) Tetany
Acute renal failure caused by parenchymal damage to the glomeruli of kidney tubules results in
all of the following except:
A) Decreased GFR.
B) Increased urine specific gravity.
C) Impaired electrolyte balance.
D) Progressive azotemia.
Oliguria is a clinical sign of ARF that refers daily to a urine output of:
A) 1.5L
B) 1.0L
C) Less than 400 ml
D) Less than 50 ml
Hyperkalemia is a serious electrolyte imbalance that occurs in ARF and results from:
A) Decreased GFR.
B) Increased urine specific gravity.
C) Impaired electrolyte balance.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-
rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse
responsible for this patient's care, you would anticipate a physician order for what action?
A) Perform endotracheal intubation and initiate mechanical ventilation.
B) Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and
mouth.
C) Administer furosemide (Lasix) 100 mg IV push stat.
D) Call a code for respiratory arrest.
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway
management should you delegate to a nursing assistant?
A) Assisting the patient to sit up on the side of the bed.
B) Instructing the patient to cough effectively.
C) Teaching the patient to use incentive spirometry.
D) Auscultation of breath sounds every 4 hours.
When assessing a 22-year old patient who required emergency surgery and multiple transfusion
3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38
breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal
cannula. Which action is most appropriate?
A) Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10
minutes.
B) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he
coughs.
C) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the
hyperventilation.
D) Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to
discuss the patient's status.
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7
mEq/L. Which intervention is delegated correctly to the student nurse?
A) Give potassium 10 mEq orally
B) Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
C) Give spironolactone (Aldactone) 25 mg orally
D) Assess the electrocardiogram (ECG) strip for tall T waves
ECF is primarily composed of:
A) Aqueous fluid and lymphatic fluid.
, B) CSF and interstitial fluid.
C) Interstitial and intravascular fluids.
D) Vascular fluid and CSF.
A clinical manifestation not found in hypokalemia is:
A) Muscle weakness
B) Oliguria
C) Postural hypotension
D) Bradycardia
Nursing intervention for a patient with a diagnosis of hyponatremia includes all of the following
except:
A) Assessing for symptoms of nausea and malaise.
B) Encouraging the intake of low-sodium liquids such as coffee or tea.
C) Monitoring neurologic status
D) Restricting tap water intake.
The most characteristic manifestation of hypocalcemia and hypomagnesemia is:
A) Anorexia and nausea.
B) Constipation
C) Lack of coordination
D) Tetany
Acute renal failure caused by parenchymal damage to the glomeruli of kidney tubules results in
all of the following except:
A) Decreased GFR.
B) Increased urine specific gravity.
C) Impaired electrolyte balance.
D) Progressive azotemia.
Oliguria is a clinical sign of ARF that refers daily to a urine output of:
A) 1.5L
B) 1.0L
C) Less than 400 ml
D) Less than 50 ml
Hyperkalemia is a serious electrolyte imbalance that occurs in ARF and results from:
A) Decreased GFR.
B) Increased urine specific gravity.
C) Impaired electrolyte balance.
